IntraPet Ultrasound Patient Information Form

IntraPet Patient Information

Text 410-849-6867 or intrapetstaff@gmail to schedule
Please submit this form, then contact us by text or email with your requested dates. If we do not receive your text or email follow-up, the appointment will NOT be scheduled and the form auto-deletes 🐾 Thank you!

THIS INCLUDES ADD-ONS SCANS TO PREVIOUSLY CONFIRMED DATES
Date of confirmed Ultrasound Exam * LEAVE BLANK IF NOT CONFIRMED by IntraPet at this time (including add-ons)

Month Day Year
Hospital Name *
DVM name/contact
Pet name *
Owner last name
DOB (please use year, not age) *
Weight (specify lbs or kg) *
Species/Breed *
Sex *
Previous IntraPet Ultrasound? *
Date of Previous IntraPet Ultrasound
Ultrasound Exam (multiple can be selected) *
Please specify type of Special procedure if applicable
Presenting Complaint/History/PE *
Medications (Current dose & Duration)
Lab Results/Radiograph Findings (Brief description, email intrapetstaff@gmail full results)
Tentative diagnosis/ Questions to be answered with ultrasound
Please provide pre-calculated IV sedation dosages to be used in the event they are necessary to achieve a full diagnostic ultrasound. If sedation is deemed necessary by the Sonographer despite best efforts to avoid it, due to abdominal wall tension or excessive patient movement, and dosages are not available or if they are declined, a partial scan will be performed and a full scan charge may apply. Please note, we do NOT REQUIRE sedation, it is a choice made by dvm/owner with full awareness a diagnostic scan may not be acheived on some patients without sedation. Please contact us if sedation rec. needed from our specialists (*certain sedatives interfere echocardiograms, please contact us with any questions)
Sedation *

IV Sedation is approved IM Sedation is approved *must provide text contact next section* Sedation is declined
Sedation dosages to be used: (Or type “in medical notes” or “declined” if applicable) *PLEASE NOTE* if IM dose, a wait fee will be charged if no text contact is provided *
Notes, special concerns or questions *note if employee/dvm pet here:
Your Email to receive a copy of this form for your records to save or print *
example@example.com
Questions? Text or call 410-849-6867. Thank you!!
Should be Empty:

IntraPet Patient Information

Please submit this form, then contact us by text or email with your requested dates. If we do not receive your text or email follow-up, the appointment will NOT be scheduled and the form auto-deletes 🐾 Thank you!